Inhalant Abuse

of different products that may
have different pharmacological
effects. As a result, precise
categorization of inhalants is
difficult. One classification system
lists four general categories
of inhalants?volatile solvents,
aerosols, gases, and nitrites?
based on the form in which they
are often found in household,
industrial, and medical products.
Volatile solvents are liquids
that vaporize at room temperatures.
They are found in a
multitude of inexpensive, easily
available products used for
common
household
and industrial
purposes.
These include
paint thinners
and removers,
dry-cleaning
fluids,
degreasers,
gasoline,
glues, correction
fluids,
and felt-tip
marker fluids.
INHALANT
Abuse
such as glues, nail polish remover,
lighter fluid, spray paints, deodorant
and hair sprays, canned whipped
cream, and cleaning fluids are widely
available. Many young people inhale
the vapors from these sources in
search of quick intoxication without
being aware of the serious health
consequences that can result.
National surveys indicate that more
than 22.9 million Americans have
abused inhalants at least once in their
lives. NIDA's Monitoring the Future
study reveals that approximately 16
percent of eighth-graders have abused
inhalants. Parents and children need
to know that experimentation with
these substances should not be taken
lightly. Even a single session of repeated
inhalant abuse can disrupt heart
rhythms and cause death from cardiac
arrest or lower oxygen levels enough to
cause suffocation. Regular abuse of
these substances can result in serious
harm to vital organs including the
brain, heart, kidneys, and liver.
Through scientific research, we
have learned much about the nature
and extent of inhalant abuse, its
pharmacology, and its consequences.
This research has brought the picture
of inhalant abuse in our Nation into
focus and pointed to the dangers
and the warning signs for parents,
educators, and clinicians. We hope
this compilation of the latest scientific
information will help alert readers
to inhalant abuse and its harmful
effects and aid efforts to deal with this
problem effectively.
Nora D.Volkow,M.D.
Director
National Institute on Drug Abuse
U . S . D e p a r t m e n t o f H e a l t h a n d H u m a n S e r v i c e s| N a t i o n a l I n s t i t u t e s o f H e a l t h
What are
inhalants?
Inhalants are volatile substances
that produce chemical
vapors that can be inhaled
to induce a psychoactive, or
mind-altering, effect. Although
other abused substances can be
inhaled, the term ?inhalants? is
used to describe a variety of
substances whose main common
characteristic is that they are
rarely, if ever, taken by any route
other than inhalation. This definition
encompasses a broad range
of chemicals found in hundreds
Aerosols are sprays that
contain propellants and solvents.
They include spray paints,
deodorant and hair sprays,
vegetable oil sprays for cooking,
and fabric protector sprays.
Gases include medical anesthetics
as well as gases used in
household or commercial products.
Medical anesthetic gases
include ether, chloroform,
halothane, and nitrous oxide,
commonly called ?laughing gas.?
Nitrous oxide is the most abused
of these gases and can be found
in whipped cream dispensers
and products that boost octane
levels in racing cars. Household
or commercial products containing
gases include butane lighters,
propane tanks, whipped cream
dispensers, and refrigerants.
Nitrites often are considered a
special class of inhalants. Unlike
most other inhalants, which act
directly on the central nervous
system (CNS), nitrites act primarily
to dilate blood vessels and relax
the muscles. And while other
inhalants are used to alter mood,
nitrites are used primarily as
sexual enhancers. Nitrites include
cyclohexyl nitrite, isoamyl (amyl)
nitrite, and isobutyl (butyl)
nitrite. Cyclohexyl nitrite is found
in room odorizers. Amyl nitrite is
used in certain diagnostic procedures
and is prescribed to some
patients for heart pain. Illegally
diverted ampules of amyl nitrite
are called ?poppers? or ?snappers?
on the street. Butyl nitrite is
an illegal substance that is often
packaged and sold in small bottles
also referred to as ?poppers.?
What are the
patterns of
inhalant abuse?
Inhalants?particularly
volatile solvents, gases, and
aerosols?are often among
the first drugs that young children
use. One national survey indicates
that about 3.0 percent of U.S.
children have tried inhalants by
the time they reach fourth grade.
Inhalants also are one of the
few substances abused more by
younger children than by older
ones. Nevertheless, inhalant
abuse can become chronic and
extend into adulthood.
Generally, inhalant abusers
will abuse any available substance.
However, effects produced
by individual inhalants
vary, and some individuals will
go out of their way to obtain
their favorite inhalant. For
example, in certain parts of the
country, ?Texas shoe-shine,? a
shoe-shining spray containing
the chemical toluene, is a local
favorite. Silver and gold spray
paints, which contain more
toluene than other spray colors,
also are popular inhalants.
Data from national and State
surveys suggest inhalant abuse
reaches its peak at some point
during the seventh through ninth
grades. In the Monitoring the
Future (MTF) study, an annual
NIDA-supported survey of the
Nation?s secondary school students,
8th-graders also regularly
report the highest rate of current,
past year, and lifetime inhalant
abuse; 10th- and 12th-graders
report less abuse.
2NIDA RESEARCH REPORT SERIES
Students who have ever used inhalants
versus other commonly abused drugs, percent
Marijuana
Cocaine
LSD
Inhalants
8th
10th
12th
Grade
Percentage
Source: Monitoring the Future Survey, 2003
0 10 20 30 40 50
Gender differences in inhalant
abuse have been identified at
different points in childhood. The
2003 MTF indicates that 9.6 percent
of 8th grade females reported
using inhalants in the past year
compared with 7.7 percent of
8th grade males. Among 12thgraders,
2.9 percent of females
and 5.2 percent of males reported
using inhalants in the past year.
The National Survey on Drug
Use and Health (NSDUH),
an annual survey of drug use
among the Nation?s noninstitutionalized
civilians, reports that
similar percentages of 12- to 17-
year-old boys and girls abused
inhalants in 2002. However, the
percentage of 18- to 25-year-old
males who abused inhalants
within the past month and
within the past year was more
than twice that of females in
that age group, suggesting that
sustained abuse of inhalants is
more common among males.
People who abuse inhalants
are found in both urban and
rural settings. Research on factors
contributing to inhalant abuse
suggests that adverse socioeconomic
conditions, rather than
racial or cultural factors per se,
may account for most reported
racial and ethnic differences in
rates of inhalant abuse. Poverty,
a history of childhood abuse,
poor grades, and dropping out
of school all are associated with
inhalant abuse.
What is the
scope of
inhalant abuse?
Past-year inhalant abuse
among the Nation?s 10thand
12th-graders declined
in 2003, continuing an apparent
gradual decline that began in
1996, according to the latest
MTF data. However, past year
use among 8th-graders increased
between 2002 and 2003. For
example:
? The number of high school
seniors who abused any
inhalants in the past year
declined to 3.9 percent
in 2003 from a peak of
8.0 percent in 1995.
? Abuse of all inhalants by
10th-graders declined to 5.4
percent in 2003, down from
a high of 9.6 percent in 1995.
? Among 8th-graders, 2003
abuse figures, at 8.7 percent,
were down overall from the
1995 peak of 12.8 percent,
but were up from the 2002
rate of 7.7 percent.
Despite the declines in abuse
among schoolchildren in recent
years, inhalants are still being
abused at high rates, according
to the NSDUH. The 2002 survey
indicates that lifetime, past year,
and past month inhalant use
among persons aged 12 to 17
were 10.5 percent, 4.4 percent,
and 1.2 percent, respectively.
The number of new inhalant
users increased from 627,000
new users in 1994 to 1.2 million
in 2000. During this period,
more males than females initiated
inhalant use. The number of
new inhalant users in 2001 was
similar to the number in 2000
NIDA RESEARCH REPORT SERIES3
Trends in current use* of inhalants, 1995-2003
*Used within the 30 days preceding the survey. Source: Monitoring the Future Survey, 2003
8%
6
4
2
0
1995 1997 1999 2001 2003
?

?
?

?

?
?

8th-graders
10th-graders
12th-graders
(1.1 million). Inhalant initiates
in 2001, as well as in prior years,
were predominantly under age
18 (71 percent in 2001).
MTF?s lifetime prevalence
figures indicate that the percentages
of students who have tried
inhalants continue to decrease
steadily for 10th- and 12thgraders.
In 2003, 12.7 percent
of 10th-graders and 11.2 percent
of 12th-graders said they have
abused inhalants at least once
in their lives. For 8th-graders,
lifetime prevalence peaked
at 21.6 percent in 1995. For
10th-graders, the peak was
19.3 percent in 1996. For seniors,
rates were highest in 1994 at
17.7 percent. These data raise
a question: How can fewer
12th-graders than 8th-graders
consistently report they have
ever abused inhalants? Possibly,
many 12th-graders fail to recall
their much earlier use of
inhalants or, more troubling,
many 8th-grade inhalant abusers
may have dropped out of school
by the 12th grade and are no
longer included in the survey
population.
How are
inhalants used?
Inhalants can be breathed
in through the nose or the
mouth in a variety of ways,
such as:
? ?Sniffing? or ?snorting?
fumes from containers;
? Spraying aerosols directly
into the nose or mouth;
? ?Bagging??sniffing or inhaling
fumes from substances
sprayed or deposited inside
a plastic or paper bag;
? ?Huffing? from an inhalantsoaked
rag stuffed in the
mouth; and
? Inhaling from balloons filled
with nitrous oxide.
Inhaled chemicals are rapidly
absorbed through the lungs into
the bloodstream and quickly
distributed to the brain and
other organs. Within minutes of
inhalation, the user experiences
intoxication along with other
effects similar to those produced
by alcohol. Alcohol-like effects
may include slurred speech, an
inability to coordinate movements,
euphoria, and dizziness.
In addition, users may experience
lightheadedness, hallucinations,
and delusions, such as thinking
they can fly.
Because intoxication lasts
only a few minutes, abusers
frequently seek to prolong the
high by continuing to inhale
repeatedly over the course of
several hours, a very dangerous
practice. With successive
inhalations, abusers can suffer
loss of consciousness and death.
At the least, they will feel less
inhibited and less in control.
After heavy use of inhalants,
abusers may feel drowsy for
several hours and experience a
lingering headache.
4NIDA RESEARCH REPORT SERIES
How can inhalant abuse be recognized?
Early identification and intervention are the best ways to stop
inhalant abuse before it causes serious health consequences.
Parents, educators, family physicians, and other health care
practitioners should be alert to the following signs of a serious
inhalant abuse problem:
? Chemical odors on breath
or clothing
? Paint or other stains on
face, hands, or clothes
? Hidden empty spray paint
or solvent containers and
chemical-soaked rags or
clothing
? Drunk or disoriented
appearance
? Slurred speech
? Nausea or loss of
appetite
? Inattentiveness, lack of
coordination, irritability,
and depression
How do inhalants
produce their
effects?
Many brain systems may
be involved in the anesthetic,
intoxicating, and
reinforcing effects of different
inhalants. Nearly all abused
inhalants (other than nitrites)
produce a pleasurable effect by
depressing the CNS. Evidence
from animal studies suggests that
a number of commonly abused
volatile solvents and anesthetic
gases have neurobehavioral
effects and mechanisms of action
similar to those produced by
CNS depressants, which include
alcohol and medications such as
sedatives and anesthetics.
A recent study indicates
that toluene, a solvent
found in many commonly
abused inhalants, including
airplane glue, paint sprays,
and paint and nail polish
removers, activates the
brain?s dopamine system.
The dopamine system has
been shown to play a role
in the rewarding effects
of many drugs of abuse.
Nitrites, in contrast, dilate
and relax blood vessels
rather than acting as
anesthetic agents.
What are
the short-
and long-term
effects of
inhalant use?
Although the chemical
substances found
in inhalants may
produce various pharmacological
effects, most
inhalants produce a rapid
high that resembles alcohol
intoxication with initial
excitation, then drowsiness,
disinhibition, lightheadedness,
and agitation. If
sufficient amounts are inhaled,
nearly all solvents and gases
produce anesthesia, a loss of sensation,
and even unconsciousness.
The chemicals found in solvents,
aerosol sprays, and gases
can produce a variety of additional
effects during or shortly
after use. These effects are
related to inhalant intoxication
and may include belligerence,
apathy, impaired judgment, and
impaired functioning in work
or social situations. Dizziness,
drowsiness, slurred speech,
lethargy, depressed reflexes,
general muscle weakness, and
stupor are other possible effects.
For example, research shows
that toluene can produce
headache, euphoria, giddy feelings,
and inability to coordinate
movements. Exposure to high
doses can cause confusion and
delirium. Nausea and vomiting
are other common side effects.
Inhaled nitrites dilate blood
vessels, increase heart rate, and
produce a sensation of heat
and excitement that can last for
several minutes. Other effects
can include flush, dizziness, and
headache. Unlike other inhalants,
which are abused mainly for
their intoxicating effects, nitrites
are abused primarily because
they are believed to enhance
sexual pleasure and performance.
A strong need to continue
using inhalants has been reported
among many individuals,
particularly those who abuse
inhalants for prolonged periods
over many days. Compulsive
use and a mild withdrawal syndrome
can occur with long-term
NIDA RESEARCH REPORT SERIES5
Brain damage in a
toluene abuser
Brain images show marked atrophy (shrinkage)
of brain tissue in a toluene abuser (B) compared
to a nonabusing individual (A). Note the smaller
size and the larger empty (dark) space within
the toluene abuser's brain. (The white outer
circle in each image is the skull.)
Courtesy of Neil Rosenberg, M.D.
inhalant abuse. Additional
symptoms exhibited by longterm
inhalant abusers include
weight loss, muscle weakness,
disorientation, inattentiveness,
lack of coordination, irritability,
and depression.
What are
the medical
consequences of
inhalant abuse?
Inhalant abusers risk an array
of devastating medical consequences.
Prolonged sniffing of
the highly concentrated chemicals
in solvents or aerosol sprays
can induce irregular and rapid
heart rhythms and lead to heart
failure and death within minutes
of a session of prolonged sniffing.
This syndrome, known as
?sudden sniffing death,? can
result from a single session of
inhalant use by an otherwise
healthy young person. Sudden
sniffing death is particularly
associated with the abuse of
butane, propane, and chemicals
in aerosols. Inhalant abuse also
can cause death by:
? Asphyxiation?from repeated
inhalations, which lead to
high concentrations of
inhaled fumes displacing the
available oxygen
in the lungs;
? Suffocation?
from blocking
air from entering
the lungs
when inhaling
fumes from a
plastic bag
placed over
the head;
? Choking?from
inhalation of
vomit after
inhalant use; or
? Fatal injury?
from accidents,
including
motor vehicle
fatalities,
suffered while
intoxicated.
Animal and
human research
shows that most
inhalants are
extremely toxic. Perhaps the
most significant toxic effect of
chronic exposure to inhalants is
widespread and long-lasting
damage to the brain and other
parts of the nervous system. For
example, both animal research
and human pathological studies
indicate that chronic abuse of
volatile solvents such as toluene
damages the protective sheath
around certain nerve fibers in
the brain and peripheral nervous
system. This extensive destruction
of nerve fibers is clinically
similar to that seen with neurological
diseases such as multiple
sclerosis.
The neurotoxic effects of
prolonged inhalant abuse include
neurological syndromes that
reflect damage to parts of the
brain involved in controlling
cognition, movement, vision, and
hearing. Cognitive abnormalities
can range from mild impairment
to severe dementia. Other effects
can include difficulty coordinating
movement, spasticity, and loss of
feeling, hearing, and vision.
Inhalants also are highly
toxic to other organs. Chronic
exposure can produce significant
damage to the heart, lungs, liver,
and kidneys. Although some
inhalant-induced damage to the
nervous and other organ systems
may be at least partially reversible
when inhalant abuse is stopped,
many syndromes caused by
repeated or prolonged abuse
are irreversible.
Abuse of inhalants during
pregnancy also may place infants
and children at increased risk of
developmental harm. Animal
6NIDA RESEARCH REPORT SERIES
Nerve fiber deterioration in an
inhalant abuser
Dark-stained patches show areas where nerve fibers have
lost their protective sheath in a specimen of brain tissue
removed from a deceased inhalant abuser.
Reproduced with permission from the Journal of Neuropathology & Experimental Neurology.
studies designed to simulate
human patterns of inhalant abuse
suggest that prenatal exposure
to toluene or trichlorethylene
(TCE) can result in reduced birth
weights, occasional skeletal
abnormalities, and delayed
neurobehavioral development.
A number of case reports note
abnormalities in newborns of
mothers who chronically abuse
solvents, and there is evidence
of subsequent developmental
impairment in some of these
children. However, no wellcontrolled,
prospective study of
the effects of prenatal exposure
to inhalants in humans has been
conducted, and it is not possible
to link prenatal exposure to a
specific chemical to a specific
birth defect or developmental
problem.
What are the
special risks for
nitrite abusers?
Nitrites are abused mainly
by older adolescents and
adults. Typically, individuals
who abuse nitrites are seeking
to enhance sexual function
and pleasure. Research shows
that abuse of these drugs in this
context is associated with unsafe
sexual practices that greatly
increase the risk of contracting
and spreading such infectious
diseases as HIV/AIDS and
hepatitis.
Animal research raises the
possibility that there may be a
link between abuse of nitrite
inhalants and the development
and progression of infectious
diseases and tumors. The
research indicates that inhaling
nitrites depletes many cells in the
immune system and impairs
immune system mechanisms that
fight infectious diseases. A recent
study found that even a relatively
small number of exposures to
butyl nitrite can produce dramatic
increases in tumor incidence and
growth rates in animals.
Where can I get
further scientific
information about
inhalant abuse?
To learn more about
inhalants and other drugs of
abuse, contact the National
Clearinghouse for Alcohol and
Drug Information (NCADI) at
1-800-729-6686. Information
specialists are available to help
NIDA RESEARCH REPORT SERIES7
Hazards of chemicals found in commonly abused inhalants
amyl nitrite, butyl nitrite
(?poppers,? ?video head cleaner?)
sudden sniffing death syndrome, suppressed immunologic
function, injury to red blood cells (interfering with oxygen
supply to vital tissues)
benzene (found in gasoline)
bone marrow injury, impaired immunologic function,
increased risk of leukemia, reproductive system toxicity
butane, propane
(found in lighter fluid, hair and paint sprays)
sudden sniffing death syndrome via cardiac effects,
serious burn injuries (because of flammability)
freon (used as a refrigerant and aerosol propellant)
sudden sniffing death syndrome, respiratory obstruction
and death (from sudden cooling/cold injury to airways),
liver damage
methylene chloride
(found in paint thinners and removers, degreasers)
reduction of oxygen-carrying capacity of blood, changes to the
heart muscle and heartbeat
nitrous oxide (?laughing gas?), hexane
death from lack of oxygen to the brain, altered perception and motor
coordination, loss of sensation, limb spasms, blackouts caused by
blood pressure changes, depression of heart muscle functioning
toluene
(found in gasoline, paint thinners and removers, correction fluid)
brain damage (loss of brain tissue mass, impaired cognition, gait
disturbance, loss of coordination, loss of equilibrium, limb spasms,
hearing and vision loss), liver and kidney damage
trichlorethylene (found in spot removers, degreasers)
sudden sniffing death syndrome, cirrhosis of the liver, reproductive
complications, hearing and vision damage
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Fact sheets, including InfoFacts,
on the health effects of inhalants,
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be ordered free of charge in
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(NCADI) at www.health.org.
References
Balster, R.L. Neural basis of inhalant abuse. Drug and
Alcohol Dependence 51(1-2):207-214, 1998.
Bowen, S.E.; Wiley, J.L.; Evans, E.B.; Tokarz, M.E.;
and Balster, R.L. Functional observational battery
comparing effects of ethanol, 1,1,1-trichlorethane,
ether, and flurothyl. Neurotoxicology and Teratology
18(5):577-585, 1996.
Edwards, R.W., and Oetting, E.R. Inhalant use in the
United States. In: Kozel, N.; Sloboda, Z.; and De La
Rosa, M. (eds.), Epidemiology of Inhalant Abuse:
An International Perspective. National Institute on
Drug Abuse Research Monograph 148. DHHS
Publication No. NIH 95-3831. Washington, DC:
U.S. Government Printing Office, 8-28, 1995.
Fendrich, M.; Mackesy-Amiti, M.E.; Wislar, J.S.; and
Goldstein, P.J. Childhood abuse and the use of
inhalants: Differences by degree of use. American
Journal of Public Health 87(5):765-769, 1997.
Jones, H.E., and Balster, R.L. Inhalant abuse in
pregnancy. Obstetrics and Gynecology Clinics of
North America 25(1):153-167, 1997.
National Institute on Drug Abuse. National Survey
Results on Drug Use From the Monitoring the Future
Study, 2003 (www.monitoringthefuture.org).
National Institute on Drug Abuse. NIDA InfoFacts,
Inhalants, 2003.
PRIDE Surveys National Summary for Grades 4 thru 6,
2002-2003.
Riegel, A.C., and French, E.D. Acute toluene induces
biphasic changes in rat spontaneous locomotor
activity which are blocked by remoxipride.
Pharmacology, Biochemistry and Behavior
62(3):399-402, 1999.
Sharp, C.W., and Rosenberg, N.L. Inhalants. In:
Lowinson, J.H.; Ruiz, P.; Millman, R.B.; and
Langrod, J.G. (eds.), Substance Abuse: A
Comprehensive Textbook, 3d. ed. Baltimore:
Williams and Wilkins, 246-264, 1996.
Sharp, C.W., and Rosenberg, N. Inhalant-related
disorders. In: Tasman, A.; Kay, J.; and Lieberman,
J.A. (eds.), Psychiatry, Vol. 1. Philadelphia:
W.B. Saunders, 835-852, 1997.
Substance Abuse and Mental Health Services
Administration. National Findings From the
2002 National Survey on Drug Use and Health.
SAMHSA, 2002.
Soderberg, L.S. Immunomodulation by nitrite inhalants
may predispose abusers to AIDS and Kaposi?s
sarcoma. Journal of Neuroimmunology
83(1-2):157-161, 1998.
Soderberg, L.S. Increased tumor growth in mice
exposed to inhaled isobutyl nitrite. Toxicology
Letters 101(1-2):35-41, 1999.
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NIDA Web Sites
www.drugabuse.gov
www.steroidabuse.org
www.clubdrugs.org
NCADI
Web Site: www.health.org
Phone No.: 1-800-729-6686
NIH Publication Number 00-3818
Printed 1994, Reprinted 1996, 1999, Revised July 2000,
Revised March 2004
Feel free to reprint this publication.
8NIDA RESEARCH REPORT SERIES
Glossary
Anesthetic: An agent that causes insensitivity to pain.
Central nervous system: The brain and spinal cord.
Dementia: A condition of deteriorated mentality.
Dopamine: A neurotransmitter present in regions of
the brain that regulate movement, emotion, motivation,
and feeling of pleasure.
Epidemiology: The sum of the factors controlling the
presence or absence of a disease or condition.
Toxic: Causing temporary or permanent effects that
are detrimental to the functioning of a body organ or
group of organs.
Withdrawal: A variety of symptoms that occur after
use of an addictive drug is reduced or stopped.